Schedule L Benefit Comparison and Actuarial Attestation.xlsx
XLSX spreadsheet 25 KB Posted
- Attached to
- HMO Services for MPSERS
- Solicitation number
- RFP 171 230000003226 2
- Issued by
- Michigan
About this file
This is a Benefit Comparison and Actuarial Attestation schedule for RFP# 230000003226 related to health insurance coverage under the MPSERS Master Health Care Plan 2024. The document outlines detailed benefit requirements for both non-Medicare and Medicare eligible populations that bidders must match or exceed with actuarially equivalent plans. Coverage areas include hospital care, emergency services, surgical services, office visits, preventive services, mental health services, substance use disorder treatment, durable medical equipment, hearing care, and prescription drugs. Bidders are required to propose benefit plans that maintain actuarial equivalence to the master plan specifications and must provide attestation from a certified actuary or an underwriter demonstrating equivalence. The requirement specifies no county restrictions, with bidders responsible for listing all covered counties or applicable zip codes if partial coverage is provided.
The non-Medicare plan establishes a $1,000 individual medical deductible, a $900 individual medical coinsurance maximum, and a $1,750 individual prescription drug coinsurance maximum. The Medicare plan features a lower $800 individual medical deductible with a $900 individual medical coinsurance/copay maximum and a $1,700 total medical out-of-pocket maximum. Prescription drug cost-sharing across both plans includes 20% coinsurance for generic and preferred brand drugs with specified minimum and maximum copays, 40% coinsurance for non-preferred brands, and similar tiered coinsurance for specialty pharmacy drugs through Optum. Preventive services including routine physical exams, screenings, and specified vaccines are covered in full for both populations. All bidders must submit formal actuarial attestations either as part of their response or as a separately labeled Schedule L attachment to validate that proposed benefit designs meet the required equivalence standards.
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| Schedule K 834 Use Case and Example.docx | DOCX document | |
| Schedule M HMO Census Data REVISED.xlsx | XLSX spreadsheet | |
| Schedule B Pricing.xlsx | XLSX spreadsheet | |
| Schedule I2 PPO Medicare Summary of Benefits.pdf | ||
| Schedule I4 Medicare Prescription Drug Summary of Benefits.pdf | ||
| Schedule F Definitions.docx | DOCX document | |
| Schedule G - Contractor Performance Evaluation Survey.doc | DOC document | |
| Schedule I1 PPO Non Medicare Summary of Benefits.pdf | ||
| Schedule I3 Non-Medicare Prescription Drug Summary of Benefits.pdf | ||
| 230000003226 HMO Services RFP.docx | DOCX document | |
| Schedule N Section 2 Solutions Table.xlsx | XLSX spreadsheet | |
| 230000003226 Questions Answers.pdf | ||
| Schedule Q RFI Report Template.xlsx | XLSX spreadsheet | |
| Schedule R Payment Discrepancy Report Template.xlsx | XLSX spreadsheet |
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Text version
Non Medicare
| SCHEDULE L - BENEFIT COMPARISON AND ACTUARIAL ATTESTATION |
| RFP# 230000003226 |
| Instructions: |
Benefits: Enter bidder's proposed benefit coverage in the designated Bidder Response column. Bidders note that the benefit details of Bidder's proposed plan are at the Bidder's discretion. The requirement is that the plan be actuarially equivalent to the benefits listed below. See Schedule A, Section 1.2.1.
Counties: List each covered county. If a county is only covered partially, list out each covered zip code within that county.
Actuarial Equivalence: Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter. This may be provided as a separate attachment. If providing separately, clearly label as Schedule L- Actuarial Attestation.
| Benefit | MPSERS Master Health Care Plan 2024 | Bidder Response |
| Non Medicare Benefits Summary Comparison | ||
| Hospital Care | ||
| Inpatient hospital care | 10% coinsurance plus deductible. | |
| Outpatient hospital care, including diagnostic services | 10% coinsurance plus deductible. | |
| Alternatives to Hospital Care | ||
| Home healthcare | Deductible. | |
| Skilled nursing facility | 10% coinsurance plus deductible up to 100 days (can be renewed). | |
| Hospice | Covered in full. | |
| Emergency Services | ||
| Emergency room care | 10% coinsurance plus deductible, $135 copay/visit after coinsurance maximum met.** Waived if admitted within 72 hours. | |
| Urgent care | 10% coinsurance plus deductible, $65 copay/visit after coinsurance maximum met.** | |
| Surgical Services | ||
| Surgical services | 10% coinsurance, plus deductible. | |
| Doctor Office Visits and Services | ||
| Office visits | 10% coinsurance, plus deductible. | |
| Online visits | 10% coinsurance, plus deductible. | |
| Allergy testing and treatment | 10% coinsurance, plus deductible. | |
| Chiropractic visits | 10% coinsurance, plus deductible, up to 26 visits annually. | |
| Physical, occupational, speech therapy | 10% coinsurance, plus deductible. | |
| Preventive Services | ||
| Annual routine physical exams | Covered in full. | |
| Routine pap smears | Covered in full. | |
| Routine mammograms | Covered in full. | |
| Screening colonoscopy | Covered in full. | |
| Vaccines (Influenza, Pneumonia, Hepatitis B, COVID-19) | Covered in full.*** |
Additional vaccines are covered under the prescription drug plan.
| Mental Health | |
| Outpatient mental health services | 10% coinsurance, plus deductible. |
| Substance Use Disorder Treatment | |
| Outpatient facility | 10% coinsurance, plus deductible. |
| Durable Medical Equipment | |
| Durable medical equipment | Approved provider: 10% coinsurance, plus deductible. |
| Non-approved provider: 30% coinsurance, plus deductible and difference in cost between supplier’s charge and the Blue Cross approved amount. | |
| Hearing | |
| Routine hearing care | Hearing exam: $45 copay.** |
| Hearing aids: | |
| $499 copay** per hearing aid for advanced aids. | |
| $799 copay** per hearing aid for premium aids. | |
| Initial hearing exam and hearing aids for both ears covered once every 36 months, exclusively through TruHearing providers. | |
| Location of Care | |
| Care in Michigan, but outside the network | Additional 20% coinsurance, waived if member has referral from Blue Preferred PPO physician. If provider does not participate with Blue Cross, member also pays difference between the approved amount and provider’s charge. Routine hearing care is only covered when members use TruHearing providers. |
| Care outside Michigan | Same in U.S. and its territories; emergency and urgent care outside U.S., member pays cost of care up front and files for reimbursement. |
| Medical Deductible | |
| Deductible | $1,000 individual.**** |
| The amount you pay each year before the plan pays | |
| Medical Maximum | |
| Medical coinsurance maximum | $900 individual. |
| The maximum amount of coinsurance paid in a calendar year for in-network services | |
| Prescription Drugs | |
| Traditional prescription drugs | Generic and Preferred Brand: 20% coinsurance with $15 minimum/$45 maximum (31 day); $37.50 minimum /$112.50 maximum (90 day). |
| Non-Preferred Brand: 40% coinsurance with $15 minimum/no maximum (31 day); $37.50 minimum/ no maximum (90 day). |
Specialty prescription drugs Optum Specialty Pharmacy:
Preferred Specialty: 20% coinsurance with $50 minimum/$100 maximum (30 day).
Non-Preferred Specialty: 40% coinsurance with $50 minimum/no maximum (30 day).
Non-Preferred Pharmacy:
40% coinsurance with $50 minimum / no maximum
| Prescription Drug Maximum | |
| Prescription drug coinsurance maximum | $1,750 individual. |
Notes: *This document is only a summary. Benefit levels are subject to change.
**Copays are not included in the medical coinsurance maximum ****Members enrolled in the LivingWell program have the opportunity to reduce their deductible.
| Counties: | |
| *Please list each covered county. | No county restrictions. |
Actuarial Equivalence Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter.
Medicare
| SCHEDULE L - BENEFIT COMPARISON AND ACTUARIAL ATTESTATION |
| RFP# 230000003226 |
| Instructions: |
Benefits: Enter bidder's proposed benefit coverage in the designated Bidder Response column. Bidders note that the benefit details of Bidder's proposed plan are at the Bidder's discretion. The requirement is that the plan be actuarially equivalent to the benefits listed below. See Schedule A, Section 1.2.1.
Counties: List each covered county. If a county is only covered partially, list out each covered zip code within that county.
Actuarial Equivalence: Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter. This may be provided as a separate attachment. If providing separately, clearly label as Schedule L- Actuarial Attestation.
| Benefit | MPSERS Master Health Care Plan 2024 | Bidder Response |
| Medicare Benefits Summary Comparison | ||
| Hospital Care | ||
| Inpatient hospital care | 10% coinsurance, plus deductible. | |
| Outpatient hospital care, including diagnostic services | 10% coinsurance, plus deductible. | |
| Alternatives to Hospital Care | ||
| Home healthcare | Covered in full. | |
| Skilled nursing facility | 10% coinsurance plus deductible, up to 100 days. Can be renewed. | |
| Hospice | Covered by Original Medicare. | |
| Emergency Services | ||
| Emergency room care | $135 copay, waived if admitted within 72 hours. | |
| Urgent care | $65 copay. | |
| Surgical Services | ||
| Surgical services | 10% coinsurance, plus deductible. | |
| Doctor Office Visits and Services | ||
| Office visits | 10% coinsurance, plus deductible. | |
| Online visits | 10% coinsurance, plus deductible. | |
| Allergy testing and treatment | 10% coinsurance, plus deductible. | |
| Chiropractic visits | 10% coinsurance, plus deductible. | |
| Physical, occupational, speech therapy | 10% coinsurance, plus deductible. | |
| Preventive Services | ||
| Annual routine physical exam | Covered in full. | |
| Routine pap smears | Covered in full. | |
| Routine mammograms | Covered in full. | |
| Colorectal cancer screenings | Covered in full. | |
| Vaccines (Influenza, Pneumonia, Hepatitis B, COVID-19) | Covered in full. |
Additional vaccines are covered under the prescription drug plan.
| Mental Health | |
| Outpatient mental health services | 10% coinsurance, plus deductible. |
| Substance Use Disorder Treatment | |
| Outpatient facility | 10% coinsurance, plus deductible. |
| Durable Medical Equipment | |
| Durable medical equipment supplier | In network: 10% coinsurance plus deductible. |
| Out of network: 30% coinsurance plus deductible. | |
| Hearing | |
| Routine hearing care | Hearing exam: $45 copay.** |
| Hearing aids: $499 copay** per hearing aid for advanced aids. $799 copay** per hearing aid for premium aids. | |
| Initial hearing exam and hearing aids for both ears covered once every 36 months, exclusively through TruHearing providers. | |
| Location of Care | |
| Care in Michigan, but outside the network | Same as in network, except durable medical equipment. Routine hearing care is only covered when members use TruHearing providers. |
| Care outside of Michigan | Same in U.S. and its territories; emergency and urgent care outside U.S., member pays cost of care up front and files for reimbursement. |
| Medical Deductible | |
| Deductible | $800 individual.*** |
| The amount you pay each year before the plan pays | |
| Medical Maximums | |
| Medical coinsurance/copay maximum | $900 individual.** |
| The maximum amount of coinsurance and copays paid in a calendar year for in-network services | |
| Total medical out-of-pocket maximum | $1,700 individual.** |
| Deductible + coinsurance / copay maximum | |
| Prescription Drugs | |
| Traditional prescription drugs | Generic and Preferred Brand: 20% coinsurance with $15 minimum/$45 maximum (30 day); $37.50 minimum/$112.50 maximum (90 day). |
| Non-Preferred Brand: 40% coinsurance with $15 minimum/no maximum (30 day); $37.50 minimum/ no maximum (90 day). |
| Specialty prescription drugs | Optum Specialty Pharmacy: |
| Preferred Specialty: 20% coinsurance with $50 minimum/$100 maximum (30 day). | |
| Non-Preferred Specialty: 40% coinsurance with $50 minimum/no maximum (30 day). | |
| Non-Preferred Pharmacy: | |
| 40% coinsurance with $50 minimum/no maximum. | |
| Prescription Drug Maximum | |
| Prescription drug coinsurance maximum | $1,750 individual. |
Notes: *This document is only a summary. Benefit levels are subject to change.
**Copays for routine hearing care are not included in the medical maximums.
***Medicare members are automatically enrolled in the LivingWell program and have a lower deductible for being part of the program.
| Counties: | |
| *Please list each covered county. | No county restrictions. |
Actuarial Equivalence Bidder must submit an Attestation of Actuarial Equivalence certified by an actuary or a demonstration of actuarial equivalence from an underwriter.
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